Medical Form

These forms are confidential and will only be used in case of an emergency situation. If you have any questions please reach out to our membership manager.

Name*

First Last

Birthdate*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Doctor's Name*

Phone Number*

Medical Insurance*

Policy Number*

Insurance Card Upload*

Please take front and back pictures of your insurance card and upload them here.

Drop files here or

Max. file size: 512 MB, Max. files: 2.

Emergency Contacts

Emergency Contact #1*

First Last

Phone Number*

Email*

Emergency Contact #2

First Last

Phone Number

Email

Travel Consent (for Members Under 18)

By entering my child's name and signing my digital signature I give my child permission to travel with the Hawthorne Caballeros to various rehearsals and performances.

Child Name

Parent Digital Signature

Date

Personal or Parental Authorization

In the event I (or my child) require(s) medical care (as determined by the administration or medical services) while participating with the Hawthorne Caballeros, and am not able to sign for myself (or my child), the signature below acts as an authorization for the doctors and/or hospital to performa all necessary procedures, and render treatment including the administration or anesthesia, as necessary. I understand that attempts will be made to contact my family and/or emergency contact listed on this form as necessary before initiating this authorization.

Digital Signature*

Date*

Parent Digital Signature (if under 18)

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Medical Form

Emergency Contacts

Medical Information

Travel Consent (for Members Under 18)

Personal or Parental Authorization

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